What are the likely etiologies and recommended evaluation and management for a 75‑year‑old woman with type 2 diabetes mellitus, hypertension, prior cerebrovascular accident, and coronary artery disease who has bilateral oral soreness for two months that worsens with spicy or mint‑flavored foods?

Bilateral Oral Soreness in a 75-Year-Old Woman with Diabetes and Cardiovascular Disease

This patient most likely has burning mouth syndrome (BMS), a chronic neuropathic pain disorder that presents with bilateral burning oral pain worsened by irritating foods, and requires exclusion of secondary causes followed by reassurance, dietary modifications, and consideration of neuropathic pain medications.

Most Likely Diagnosis: Burning Mouth Syndrome

The clinical presentation strongly suggests primary burning mouth syndrome based on several key features:

• Bilateral distribution affecting the tongue, lips, palate, or buccal mucosa is characteristic of BMS, distinguishing it from unilateral neuralgias 1
• Continuous burning or stinging quality that worsens with spicy or minty foods matches the typical BMS pattern 1
• Post-menopausal age group (75-year-old woman) fits the predominant demographic for BMS 1
• Chronic duration (2 months) is consistent with BMS, which is a persistent condition 1

BMS represents a disorder of peripheral nerve fibers with central brain changes, confirmed by neurophysiological testing, biopsies, and functional MRI 1. The oral mucosa typically appears normal on examination 1.

Critical Secondary Causes to Exclude

Before confirming primary BMS, you must systematically rule out secondary causes that can present identically:

High-Priority Exclusions in This Patient

• Oral candidiasis: Particularly important given her diabetes, which increases fungal infection risk 1, 2. Examine for white plaques, erythema, or angular cheilitis. Consider empiric antifungal trial with nystatin suspension or miconazole gel if clinical suspicion exists 3

• Xerostomia (dry mouth): Diabetes causes salivary gland hypofunction in 14% of diabetic patients 2. Assess for medications causing anticholinergic effects 4. Check for thick saliva, difficulty swallowing dry foods 1

• Diabetic neuropathy: Burning mouth sensation occurs in 10% of diabetic patients and correlates with poor glycemic control 2. Her diabetes history makes this a key consideration, as neuropathy was significantly associated with oral complications (P=0.0156) 2

• Medication side effects: Review all current medications for drugs causing oral dysesthesia or xerostomia 1

• Nutritional deficiencies: Check complete blood count, iron studies, B12, and folate levels, as hematological disorders can cause secondary BMS 1

• Autoimmune disorders: Though less likely with normal-appearing mucosa, consider if examination reveals any mucosal lesions 1

Diagnostic Evaluation

Essential History Elements

• Exact location and bilateral nature of symptoms 1
• Character of pain: burning, stinging, itchy, or sore 1
• Temporal pattern: continuous versus intermittent, any pain-free periods 1
• Aggravating factors: specific foods (spicy, acidic, hot, minty), eating in general 1, 4
• Associated symptoms: dry mouth, abnormal taste (dysgeusia), phantogeusia 1
• Impact on quality of life: depression is commonly associated with BMS 1
• Complete medication review including over-the-counter products 4

Physical Examination

• Oral mucosa appearance: BMS shows normal mucosa; any visible lesions suggest alternative diagnosis 1
• Assess for candidiasis: white plaques, erythema, angular cheilitis 3
• Evaluate salivary flow: dry mucosa, thick saliva 1
• Check for mucosal lesions: ulcers, erosions, or blisters would indicate other pathology 4
• Dental examination: rule out odontogenic sources, ill-fitting dentures 4

Laboratory Testing

• Fasting and postprandial glucose: Poor glycemic control correlates with oral complications in diabetes (P=0.003 and P=0.0003 respectively) 2
• Hemoglobin A1c: assess diabetes control 2
• Complete blood count: screen for anemia 1
• Iron studies, B12, folate: exclude nutritional deficiencies 1
• Consider fungal culture if candidiasis suspected 3

Management Algorithm

Step 1: Immediate Symptomatic Relief and Dietary Modifications

• Avoid painful stimuli: eliminate spicy foods, acidic foods (tomatoes, citrus), hot drinks, minty products, alcohol, and rough-textured foods 1, 3, 4
• Choose cool, soft, bland foods that are easier to tolerate 3
• Consider cold foods like popsicles or ice cream for temporary numbing effect 3
• Maintain adequate hydration: drink ample fluids to keep mouth moist 1, 3

Step 2: Basic Oral Care Protocol

• Rinse mouth with alcohol-free mouthwash or warm saline 4-6 times daily 3
• Use soft toothbrush after meals and before bedtime 1, 3
• Apply lip balm or cream to lips if affected, avoiding chronic petroleum jelly use as it promotes mucosal dehydration 1, 4
• If dentures present: remove during oral care, clean thoroughly, defer wearing as much as possible 1

Step 3: Pharmacologic Management

For mild symptoms (Grade 1):

• Topical measures first: viscous lidocaine 2% applied to affected areas for direct pain relief 1, 3
• Benzydamine hydrochloride oral rinses or sprays every 3 hours, particularly before eating 3
• High-potency topical steroids (gel or dental paste preferred) 1

For moderate to severe symptoms (Grade 2-3):

• Gabapentin is the most evidence-supported systemic option. One study combining gabapentin 300 mg with alpha lipoic acid showed the best outcome, though RCT evidence for BMS remains limited 1
• Topical clozapine, diazepam, or capsaicin showed some effect in trials, though evidence is limited 1
• Neuropathic pain medications may be considered given the neuropathic nature of BMS 1

Step 4: Treat Secondary Causes if Identified

• If candidiasis confirmed: nystatin oral suspension or miconazole oral gel 3
• If xerostomia present: saliva substitutes, moisture-preserving mouth rinses, salivary stimulants (sugarless gum, cevimeline, or pilocarpine) 1
• If nutritional deficiency: appropriate supplementation 1
• Optimize diabetes control: target HbA1c <7% as poor control correlates with oral complications 2

Step 5: Reassurance and Cognitive Behavioral Therapy

• Crucial reassurance: Patients can be told that BMS will not get worse, which is often therapeutic in itself 1
• Set realistic expectations: Prognosis is poor with only a small number resolving fully, but symptoms can be managed 1
• Cognitive behavioral therapy (CBT): Recommended as part of management strategy for BMS 1
• Address depression: Often associated with BMS and impacts quality of life 1

Special Considerations in This Patient

Diabetes-Related Factors

Her type 2 diabetes significantly increases risk for:

• Oral candidiasis (24% prevalence in diabetics with oral complications) 2
• Xerostomia (14% prevalence) 2
• Burning mouth sensation (10% prevalence) 2
• Diabetic neuropathy manifesting as oral dysesthesia 2

Poor glycemic control (elevated FBG and PPBG) was significantly associated with oral complications 2. Optimizing her diabetes management is essential.

Cardiovascular Disease Context

While her history of stroke and coronary artery disease increases overall morbidity and mortality risk 5, 6, these conditions do not directly cause bilateral oral burning. However:

• Post-stroke pain can cause oral dysesthesia but is typically ipsilateral to the stroke, not bilateral 1
• Medication review is critical: cardiovascular medications may contribute to xerostomia 4

Common Pitfalls to Avoid

• Do not dismiss as "just anxiety": BMS is a real neuropathic disorder with demonstrable nerve fiber and brain changes 1
• Do not overlook secondary causes: Systematic exclusion of candidiasis, xerostomia, nutritional deficiencies, and medication effects is mandatory before diagnosing primary BMS 1
• Do not use plain water rinses: Use saline-containing or alcohol-free mouthwashes 3, 4
• Avoid chronic petroleum jelly on lips: It promotes mucosal dehydration and increases infection risk 1, 4
• Do not expect complete resolution: Set realistic expectations as only a small percentage fully resolve 1

When to Refer

• Dental referral: For comprehensive oral examination, management of xerostomia, and dental caries prevention 1
• Rheumatology referral: If autoimmune disorder suspected (though less likely with normal mucosa) 1
• Pain specialist: If symptoms remain refractory to initial management 1